The morning before my shift, I try to stay busy with emails, writing, cleaning the house, anything really. If I sit and think about it too long, undisturbed, I get nervous. I’m afraid to go to work, and yet I’m told I must. The flitting anxiety swells as I pull on my scrubs and head to the car. The streets are empty. I drive alone into the epicenter. It peaks when I first step through the door into the jumble of patients in chairs, stretchers, and beds crowded around our cramped workstation, staff jammed together discussing care, writing notes, calling reports. Then I start, surrounded by my colleagues, and am too busy to think about it. The fear is as much for my family and friends as for me. Probably more. I’m a physician who works in an emergency department in Washington, D.C., and the coronavirus is spreading.
I worked in Liberia at the height of the Ebola epidemic, in the fall of 2014. After only a few months, many nurses, doctors, and community health-care workers grew sick and died; most of the rest quit; and the entire health-care system collapsed. Every hospital and clinic in the country closed. We don’t ever want that to happen, no one does, but we need to act now to protect health-care workers from making that awful decision.
The COVID-19 pandemic is certainly not Ebola—the case-fatality rate is perhaps 1 percent, not 50 percent—but it raises an important practical and ethical question: How much risk do health-care workers have to take? Or, more bluntly: How many of us will die before we start to walk away from our jobs?
This is not a rhetorical question. In the SARS outbreak in Toronto, Canada, in 2003, 44 percent of all infections were in health-care providers. Two nurses and a physician died. In Arkansas, four of the first 12 COVID-19 patients were health-care workers. Last Sunday, the American College of Emergency Physicians reported that two ER doctors with COVID-19, the disease caused by the coronavirus, are being treated in intensive-care units.
In China, about 3,000 health-care workers have been infected, and 22 have died providing care for COVID-19 patients. Consider also that “transmission to family members is widely reported.”
This is the dark secret of planning for a pandemic that can also kill health-care providers and their families. When we prepare for disasters, we plan using the mnemonic “Staff, stuff, space, and systems.” We can always make more space by wedging an extra bed in, or by repurposing another building. We can buy more stuff, supplies, and equipment. We can find new supply lines, reboot our computer systems. But we cannot conjure up doctors and nurses and health-care technicians. Physicians take at least 11 years to train after high school. Nurses at least four. Techs take years or months.
The United States needs its health-care workers to see it through this crisis. But there are no replacements on the shelf. They can’t be built, trained, or repurposed from other jobs. Unless the country does dramatically more to provide them with the equipment they need to do their job safely, to assure them they will be cared for if they fall ill, and to provide their family with a measure of security, it risks losing them. What happens when they need to be quarantined? When they start to die? Or don’t come to work?
It’s hard to plan after that happens.
As I settle into the rhythm of work one recent Monday evening, the controlled chaos of the emergency department seems almost normal. Patients come and go; the crowd in the waiting room swells to more than 30 people (and their family) before dinner. The halls are lined with patients on stretchers in various states of dress and discomfort. Twelve patients are waiting for beds, blocking those spaces for the people in the waiting room.
But some things have changed. Many of us are wearing surgical masks or are muffled in N95 respirators; others have on goggles. We have converted our urgent-care section into an infectious-disease screening area. The younger staff work there, shapelessly encased in personal protective equipment (PPE).
My colleagues are remarkable. They know the risks. They go to work anyway. No one complains, just like no one says, “Good job!” or “You’re so brave!” They simply buckle down and get things done. Even in normal times, we survive on ironic, dark humor because we deal with death and sickness and the worst parts of society—violence, addiction, abuse—every day. But these days, the jokes are sometimes so sharp as to bite.
I’ve been to disasters all over the world, and I have always seen health-care providers pour in to help. Usually, within an hour, there are more than are needed—nurses, lab workers, X-ray technicians, doctors. No one has to ask; they just show up. And then they work nonstop until someone makes them take a break or they fall exhausted. It’s what we do.
But that sort of bravery, that work ethic, is not boundless. No one is so fearless or stupid as to discount all risks.
Physicians fled epidemics in ancient Greece, the black death in Europe, and the great influenza pandemic of 1918. In Vietnam, when SARS cases showed up in one hospital, most of the staff left, leaving only a few to risk their life providing care. During the West African Ebola epidemic of 2014 and ’15, at least 837 health-care workers were infected, and 490 died. The infection also spread to at least three health-care workers caring for patients with Ebola in the United States and Europe. Providers were up to 32 times more likely to be infected with Ebola than the general population.
Multiple studies have asked health-care providers whether they would go to work during various disaster scenarios. The answer is a resounding yes for earthquakes, floods, and even war. But pandemics are different. One study in 2010 found that 28 percent of the hospital staff said that they would be unlikely to respond to an influenza pandemic if asked, but not required. In a German study, 36 percent of health-care workers said they would not come to work during an influenza pandemic. For some job categories, fewer than 50 percent of workers said they would report to duty. What made workers more likely to say they would show up? Confidence that they were safe at work and getting to work, that their family was safe and cared for, and knowing their colleagues would also respond.
Family is my own biggest issue, and the one I hear most discussed sitting around the nurses’ station. Am I going to bring home an infection to my wife? A disease that could kill my kids? Health-care providers have made remarkable sacrifices to keep their family safe. In Liberia, Ebola-burial-team members moved out of their home and lived in plywood shacks for months. During the SARS outbreak, clinicians in Hong Kong and Toronto lived in their hospital. Emergency providers today have moved into their garage, rented apartments, or sent their family to live with relatives. When I got home that night, I left my shoes and bag outside, stripped just inside my front door, threw all my clothes straight in the basement washing machine set to “sanitize,” and took a 15-minute shower in the guest bath before sitting with my wife.
Sure, with COVID-19, the risk of death is low. But what are the odds that you are prepared to accept for your family? A one in 100 chance of dying? One in 10,000?
I try to live by the oath I took in medical school to treat all patients fairly and equally, even with risk to my own health. But after the West African Ebola epidemic, and now with COVID-19, I know I am not necessarily that strong. The hair stands up on the back of my neck when I hear ethicists, hospital administrators, and politicians, sitting in their safe offices, lecture me on my obligation to die providing health- care. We don’t take these risks because of an abstract “ethical duty”; we take them because it is what we do every time we walk into the chaos and danger of the emergency department. We do it because it is our job.
Yes, physicians and nurses have an ethical duty to provide care. (I have even written about it.) The perspective of medical ethicists is pretty straightforward—health-care providers, especially physicians, should continue to care for the sick even if it puts their life at risk. We have an obligation to treat all patients, because we chose our profession and are well rewarded by society with money and respect. Nurses have a similar professional duty, but have specific exemptions. But there are few, if any, obligations for all the support staff that make my work possible—the techs, clerks, registrars, environmental staff. They don’t take an oath. Some are paid minimum wage, have few benefits, and get none of the societal accolades reserved for doctors and nurses. Why should they die for a $25,000-a-year job and $10,000 worth of life insurance? Who’s going to feed their kids when they’re gone?
When you’re the one wearing a flimsy paper gown and mask in the same room as someone dying from an invisible virus that makes its home in the same air you breathe, nothing is simple.
Our duty is not boundless, and in bad situations, sacrificing providers is not what is best for society. If health-care providers are going to risk their life, then there is a reciprocal obligation—the fairness principle—that society, employers, and hospitals keep them safe and ensure that they are fairly treated, whether they live, get sick, or die.
First, hospitals must provide the resources necessary to protect the staff caring for infected patients—not just PPE, but also training, environmental controls, and policies and procedures to prevent spread. At a minimum, providers should be offered a free place to stay away from their family and be compensated for the time that they may not be able to touch their own children. Who’s going to take care of my wife and kids if I have to sleep on a cot in the hospital for two months? What about single parents whose kids are home because their schools are closed?
If someone is going to risk their life, then they deserve the best possible care to save them. We understood this during Ebola—the first treatment center built by the U.S. government in Liberia was the Monrovia Medical Unit, specifically for Ebola-infected health-care staff. Providers need the reassurance that they will get preferential access to care and medications in exchange for their sacrifice. This is not just fair, but practical—keeping clinicians alive means that they will be able to continue to provide care. Just knowing that the MMU was opening made recruiting providers easier.
Providers who become infected also deserve fair compensation—full pay while they are sick or if they are forced to quarantine to protect their patients. They should all have disability and life insurance. The families of those who sacrifice their life deserve great compensation.
I have seen little evidence of this. Emergency-physician message boards are full of concern about the lack of preparation by their hospitals. Few of these financial arrangements exist. I haven’t received any special training, mostly just a few emails about “the situation.” That doesn’t protect me. PPE is already being rationed, and there are dire predictions that it will run out long before this pandemic is over. Should I still have to go to work knowing I will get infected and have a 5 percent chance of dying? Why do my colleagues have to pay for a separate apartment when forced to self-quarantine away from their families?
Thus far, the attitude has been: What’s the big deal? It’s just COVID-19, with a mortality of less than 1 percent. But tell that to the two emergency physicians in critical care right now, or the infected health-care providers in Arkansas, Washington, New York, and other states. Tell that to their families.
Six months into the 15-month Ebola epidemic, health-care providers stopped coming to work. They had little PPE. They saw their friends die without any special care. Their colleagues began abandoning their jobs, one by one, until there was no one left. There was nowhere for people to obtain treatment for stomach pain, childbirth, heart attacks, car crashes, or any other routine or unpredictable health event. As a result, experts estimate that more people died from illnesses like malaria and diarrhea than Ebola.
When health-care providers get sick, become disabled, or die, they can no longer provide care for anyone, not just infected patients.
In Italy, at least 2,000 health-care workers have been infected and are not providing care. Some have died. Some hospitals cohort, or group, providers so that they care for only infected patients, leaving others to care for the uninfected. Others providers can’t work, because they are quarantined after possible exposures or because of known infections. But that is the way it has to be. The core ethics principle for physicians and nurses is primum non nocere—“First, do no harm”—and the last thing we want to do is spread the infection to our patients or other health-care staff.
The demand for health care is going to increase exponentially over the next few weeks, but there could be fewer and fewer providers available to share the burden. The future I see is bleak—a shift with two physicians on quarantine or sick leave, and the single backup is late. Three nurses have called out, and four techs. The waiting room is jammed, and there are people in masks sitting outside on the curb, coughing. Twenty patients are waiting for in-patient beds, but won’t go upstairs until after their COVID-19 test results return. There really aren’t any in-patient beds, anyway. It’s demoralizing. The emergency department is like an island slowly sinking into the sea, the overwhelmed waypoint between the world and the hospital, but connected to neither.
I am afraid a tipping point could happen with little warning. The loss of providers will come from many causes—quarantine, sickness, caring for their own family, cohorting—but it will be the creeping fear and feeling of abandonment that eats at us the most. A slow drip, drip, drip of attrition. Having colleagues sharing the burden is a crucial predictor for clinicians’ willingness to work despite the risk. But when the cascade starts, when you are forced to reuse your disposable face mask for the third day in a row, and another nurse doesn’t come in, because of her concern for her daughter, and you know that two of your colleagues are being treated in the ICU and another 10 are home infected, and then another physician calls out sick, and there are no clerks again today? Sooner or later, you look around and see so few standing with you. At some point, the system could break, and we will all be gone.
I gathered my things after sign-out at midnight, demoralized by what I see here and what is ahead. I’m scared. I don’t want to see my friends die, or my family, or even me. I want us to be there to help others through this whole long, painful time. Providers need the support and protection of our society and their employers so that we can meet our obligations, to our patients and to our families. Every effort has to be made and it has to start now. As I walked out of the workstation, a nurse looked up at me, fingers poised motionless over the keyboard, eyes bright above her mask. “We’re going to be all right. Aren’t we?”